Cervical ectopic pregnancy

Case contributed by Dr Amit Chakraborty

Presentation

Vaginal bleed, positive beta hCG.

Patient Data

Age: 29
Gender: Female
Ultrasound

Initial ultrasound:

  1. The uterus is anteverted, retroflexed.
  2. The endometrium is not thickened. No decidual reaction is demonstrated. 
  3. No gestational sac is see within the endometrial cavity. 
  4. Irregular gestational sac identified within the cervical canal. 
  5. Mean sac diametre 5.5mm, corresponding to a gestational age of 4 weeks.
  6. Yolk sac identified, 2mm in diametre.
  7. No foetal pole demonstrated.
  8. No FHM identified.
Ultrasound

Follow up study 2 days later

  1. Gestational sac identified again in the cervix
  2. MSD 7.6 mm, larger when compared to the study 2 days prior, corresponding to gestational age of 5 weeks 3 days
  3. Yolk sac identified again, increased in size, measuring 2.4 mm
  4. No FHM identified.
  5. The sac was non-mobile upon manipulation by transvaginal probe.
  6. No increased vascularity around the sac.
  7. No free fluid in the cervical canal
  8. No free fluid in POD

Case Discussion

This case in an example where a progress scan helps to secure the diagnosis.

The diagnostic dilemma in this instance is that of miscarriage vs cervical ectopic.

According to the Australian Sonographers Association guidelines 1 which have been adopted from UK National Institute for Health and Care Excellence (NICE) early pregnancy and miscarriage diagnosis and management guidelines 2, the MSD is well below the diagnostic threshold for miscarriage on both occasions.

Although the sac appears irregular in the first scan, there is no free fluid in the endometrial cavity. No significant vascularity is demonstrated around the gestational sac either.

During the second scan, the sac is still identified in the cervix. This time however, interval growth of the MSD and yolk sac are noted. The sac is not mobile upon cervical manipulation by TVS probe which adds further weight to the diagnosis of ectopic pregnancy. Note that there is no recordable increase in Doppler activity around the gestational sac, At an early stage of an ectopic pregnancy, increased Doppler activity and the so called 'ring of fire' sign are often not present.

Management:

  • urgent notification to the Obstetric team
  • transfer the patient to the delivery suite
  • group and crossmatch 2 units of blood
  • once treated, progress beta hCG estimation
  • follow up ultrasound examination may be recommended
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Case information

rID: 44546
Case created: 27th Apr 2016
Last edited: 2nd May 2016
System: Obstetrics
Inclusion in quiz mode: Included

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